Graduate Midwifery Education in Uganda Aiming to Improve Maternal and Newborn Health Outcomes

Background

Maternal and Neonatal Mortality

Global maternal mortality ratio (MMR) has remained

unacceptably high at 216 per 100,000 live births. It is esti-

mated that 830 women die from pregnancy-related com-

plications around the world every day [1]. In low-income

countries, one in 16 women dies of complications from

pregnancy. In developed countries, the ratio is markedly

lower, at one in 2,800 [2].

Uganda, situated in East Africa, shoulders a high MMR

of 336 per 100,000 live births, largely attributable to hem-

orrhage (34%), hypertension (19%), abortions (9%), sepsis

(8%), and indirect causes such as malaria, HIV, and other

infections (18%) [3]. Uganda also has a high neonatal mor-

tality rate (27 per 1,000 live births), mostly caused by birth

asphyxia and trauma (28.6%), prematurity (27.9%), and

sepsis (18.2%) [4].

Proven lifesaving interventions to prevent or treat

the causes of maternal and newborn deaths are well

known. They include neonatal resuscitation [5], kanga-

roo mother/father care [6], cord care with chlorhexidine

7.1% [7], antibiotic therapy, helping mother survive bleed-

ing after birth, helping mother survive preeclampsia and

eclampsia, and low-dose, high-frequency training in basic

Kumakech E, et al. Graduate Midwifery Education in Uganda Aiming to Improve

Maternal and Newborn Health Outcomes.

Annals of Global Health

2020;

86(1): 52, 1–15. DOI: https://doi.org/10.5334/aogh.2804

* Department of Nursing and Midwifery, Lira University, UG

†

Seed Global Health, US

Corresponding author: Edward Kumakech, BScN, MScN, MPH, PhD

(Edward.kumak[email protected])

VIEWPOINT

Graduate Midwifery Education in Uganda Aiming to

Improve Maternal and Newborn Health Outcomes

Edward Kumakech

, Julie Anathan

†

, Samson Udho

, Anna Grace Auma

, Irene Atuhaire

†

Allan G. Nsubuga

†

and Bonaventure Ahaisibwe

†

Background: Maternal and newborn health outcomes in Uganda have remained poor. The major challenge

aecting the implementation of maternal and newborn interventions includes a shortage of skilled

midwives. In 2013, Lira University, a Ugandan Public University, in partnership with Seed Global Health,

started the rst Bachelor of Science in Midwifery (BScM) in Uganda with a vision to develop a Master of

Science in Midwifery (MScM) in the future.

Objective: Evaluate results of Lira University’s Bachelors in Midwifery program to help inform the devel-

opment of a Masters in Midwifery program, which would expand midwifery competencies in surgical

obstetric and newborn care.

Methods: Lira University and Ministry of Health records provided data on curriculum content, student

enrollment and internships. The internship reports of the graduate midwives were reviewed to collect data

on their employment and scope of practice. Interviews were also conducted with the graduates to conrm

the added skills they were able to apply and their outcomes.

Findings: The critical competences incorporated into the Bachelor in Midwifery curriculum included com-

petences to care for pre- and post-operative caesarian section patients or assist in a caesarean section,

newborn care (e.g. resuscitation from birth asphyxia), anesthesia, and theatre techniques, among others.

Overall, 356 students (40.2% male, 59.8% female) enrolled in the BScM program over the period 2013–

2018. Annual data shows an increasing trend in enrollment. Of the 32 graduates in January 2019, 87.6%

were employed in maternal and newborn healthcare facilities, and 12.4% were employed in midwifery pri-

vate practice. Follow-up interviews revealed that the graduate midwives reported positive maternal and

newborn outcomes and the ability to practice advanced obstetrics and newborn care skills they acquired

from the training.

Conclusion: There is growing interest in a graduate midwifery education program in Uganda for both male

and female students. The retention of the graduate midwives in healthcare facilities gives a renewed hope

for mothers and newborns, who benet from their extra obstetrics and newborn care competences in set-

tings where there are neither medical doctors nor obstetricians and gynecologists.

Recommendations: Further, larger tracer studies of the graduate midwives to identify the kinds of

obstetric surgeries and newborn care services they ably performed and their corresponding maternal and

newborn health outcomes is recommended. Also recommended is advocacy for recognition of extra skills

of graduate midwives by health authorities in Uganda and the region.

Kumakech et al: Graduate Midwifery Education in Uganda Art. 52, page 2 of 15

emergency obstetrics and newborn care (EMONC) [8], and

emergency caesarian section [9].

Uganda Health System Challenges

In Uganda, as it is in many other low-income settings, the

critical challenges affecting the scale up and implementa-

tion of the aforementioned lifesaving interventions are

shortage of skilled birth attendants; [10] gaps in essential

equipment and commodities; [10–12] limited hands-on in-

service training, mentorship, coaching, and supervision of

health workers; [10–12] inappropriate training approaches

that are theoretical with inadequate simulation and prac-

tical sessions; [10] and ineffective engagement of com-

munity health workers and leaders to support last-mile

distribution of interventions and services [11, 12].

The shortage of nurses and midwives is of primary con-

cern. The nurse-midwife to patient ratio of 6:100,000 exem-

plifies the general shortage of health workers in Uganda,

which is low compared to World Health Organization

(WHO) recommendation of 2.5:1000 [13]. Figure 1 shows

how the health workforce density inversely correlates with

maternal and neonatal mortality in Uganda from World

Health Organization (WHO) Global Health Observatory,

WHO Global Atlas, World Bank, UN World Health Statistics,

and African Development Bank Group 2005–2016.

Midwifery Education and Scope of Practice

The high number of births not attended to by skilled birth

attendants is partly attributable to the inadequate num-

bers of nurse-midwives with advanced education in mid-

wifery and maternal neonatal health to address obstetrical

and perinatal emergencies.

Notably, the majority of midwives in Uganda are cer-

tificate- and diploma-level midwives who are trained to

manage normal pregnancy, labor, postpartum care, and

newborn care but not the complications of pregnancy,

labor, and newborn [10], which are the aforementioned

causes of maternal and newborn deaths. Therefore, the

problem is a lack of midwives with higher education such

as those with Bachelor’s and Master’s degrees to man-

age complications of pregnancy, labor, postpartum, and

newborn health in addition to managing normal preg-

nancy, labor, and newborn care across the healthcare

spectrum. The first-line solution to the above problem

is a Bachelor’s-level program in midwifery that imparts

the basic nursing skills plus the midwifery specialization

required to improve the high maternal and newborn prob-

lems in Uganda and the region. The second-line solution is

a Master’s level program in midwifery, with specialization

in maternal and newborn healthcare.

To justify the need to increase the scope of practice of

nurses and midwives with higher education, Dawson et al.

[14] demonstrated that obstetric surgical competence and

tasks shifting from physicians to non-physicians including

nurses and midwives are cost effective, increases access

to and availability of maternal and reproductive health

services without compromising maternal and newborn

health outcomes in Tanzania. Several other studies were

conducted in the US and England to establish the effec-

tiveness of nurse-midwives with higher education in the

different clinical nursing disciplines (also called advanced

practice nurse-midwives). Advanced practice nurse-mid-

wives are shown by various studies in other countries to

be very effective in reducing the cost of healthcare and

improving general health outcomes of individuals and

populations [15–25]. These studies highlighted many

positive contributions from the advanced practice nurse-

midwives, including improved quality healthcare services

and bringing healthcare nearer to the population among

others. Overall, the results show that nurse practitioners

and advanced practice nurses are most likely to practice

in rural settings, low economic areas, and other primary

care settings where physicians are scarce. The healthcare

services provided by the advanced practice nurses or nurse

practitioners are of high quality, low cost, and address

the prevalent diseases, health problems, and needs in

underserved populations. Related studies conducted on

quality of practice and clinical outcomes of nurse practi-

tioners and advanced practice nurses of different special-

ties found that the nurse practitioners are very relevant

and beneficial in primary care, pediatric, maternal, and

child health, mental health, geriatrics care, and also in the

management of chronic diseases.

Notably, in Uganda as it is in many low-income coun-

tries, there is considerable variation in the cadre and the

competence of midwives [26]. Unfortunately, not all sup-

posed midwives at a given health facility have the neces-

sary skills to conduct deliveries.

Although midwives with higher education in Uganda,

such as those with Master’s degrees, are neither legally

termed nor licensed as advanced practice midwives or

nurse practitioners as it is in the United States of America

(USA) and United Kingdom (UK), their scope of practice

is comparable, for example, they can both do independ-

ent practice in midwifery. It is therefore plausible to

hypothesize that they will address the health needs of

Ugandans in comparable quality and a cost-effective way

as is being done by advanced practice midwives or nurse

practitioners in the US and UK. Currently, there is no data

available from Uganda, nor from other settings compara-

ble to Uganda, about the quality and benefits of advanc-

ing midwifery education to Bachelor’s or Master’s levels.

Nevertheless, we expect the midwives with advanced edu-

cation to practice at a higher scope than their colleagues

with lower education, wherever they will be employed

to practice, because the Uganda Nurses and Midwives

Council first of all registers and license all midwives with

diploma to doctorate levels of education as “registered

Figure 1: Inverse correlation between health workforce

density and maternal and newborn mortality in Uganda

(2005–2016).

435

438

336

2910

2700 2700

131

12 12

500

1000

1500

2000

2500

3000

3500

2005/6 2010/112015/16

MMR/100,000 NMR/100,000 Nurses/100,000 Doctors/100,000

Kumakech et al: Graduate Midwifery Education in Uganda Art. 52, page 3 of 15

midwives” without any distinction in their scope of prac-

tice. Secondly, Uganda Ministry of Health national health

policy [27] defined staffing norms and minimum health-

care package by level of health facility (health centre I–IV,

general hospital, regional referral hospital, and national

referral hospital), and the definition doesn’t restrict the

employment and placement of any midwife with advanced

education to work at any level of health facility as long as

they qualify to perform the minimum healthcare pack-

age recommended to be provided at that level of health

facility. Table 1 shows an overview of the Uganda health

system, staffing norms, and role of midwives.

Therefore, if the midwives with advanced education are

employed in health centre II level, which is an outpatient

health post, they will provide health education, antena-

tal care, maternal care, and childhood care, which is the

scope of practice for midwives working in health centre

level II. If they are employed and placed at health centre

level III, which by design has an additional general ward

and maternity ward but lacks a medical doctor, they will

Table 1: Recommended maternal and newborn health (MNH) services and staffing norms in Uganda by the level of

health facility.

Health facility level Recommended MNH services Recommended MNH cadres of health

workers

National referral hospitals Provide all maternal and newborn health services

that are more comprehensive and advanced than

regional referral and general hospitals.

Professors in obstetrics and gynecology, senior

consultant obstetricians and gynecologists,

consultant obstetrician and gynecologists,

Master’s-level midwives and Bachelor’s-level

midwives

Regional referral hospitals Provide elective and emergency cesarean section

(C/S) deliveries, laparatomies for ectopic preg-

nancies, assisted deliveries (vacuum extraction),

management of referral of high-risk mothers,

management of referral of mothers with severe

complications of pregnancy, labor, postpartum,

and the newborn, normal deliveries, antenatal

care, postnatal care, newborn care, and maternal

and child immunizations. Also, provide care to

premature babies and asphyxiated newborns in

NICU with incubation and CPAP facilities.

Senior consultant obstetrician and gynecolo-

gists, consultant obstetrician and gynecolo-

gists, Bachelor’s-level doctors, Master’s-level

midwives; Bachelor’s-level midwives; diploma

midwives; and certificate midwives

District general hospitals Provide elective and emergency cesarean section

(C/S) deliveries, laparatomies for ectopic preg-

nancies, assisted deliveries (vacuum extraction),

management of high-risk mothers, management

of complications of pregnancy, labor, postpartum,

and the newborn, normal deliveries, antenatal

care, postnatal care, newborn care, and maternal

and child immunizations

Obstetricians and gynecologists; Bachelor’s-

level doctors, Master’s-level midwives;

Bachelor’s-level midwives; diploma midwives;

and certificate midwives

Health centre IV level

primary care facilities

Provide emergency cesarean section (C/S) deliver-

ies, laparatomies for ectopic pregnancies, assisted

deliveries, management of complications of

pregnancy, labor, postpartum and the newborn,

normal deliveries, antenatal care, postnatal care,

newborn care, and maternal and child immuniza-

tions

Bachelor’s-level doctors; Master’s-level

midwives; Bachelor’s-level midwives; diploma

midwives; and certificate midwives

Health center III level pri-

mary care facilities

Provide health education, antenatal care, both

presumptive and laboratory diagnosis and treat-

ment of minor disorders of pregnancy, labor,

postpartum and newborn, postnatal care, and

maternal and child immunizations

Diploma midwives and certificate midwives

Health centre II level pri-

mary health care facilities

Provide health education, antenatal care, pre-

sumptive diagnosis, and treatment of minor dis-

orders of pregnancy, postnatal care, and maternal

and child immunizations

Certificate midwives

Health Centre I level, also

known as village health

teams (VHTs)

Provide community-based preventive and promo-

tive services by community health workers such

as distribution of information, educational and

communication (IEC) materials, door-to-door

child immunization, etc.

Volunteer village health teams

Kumakech et al: Graduate Midwifery Education in Uganda Art. 52, page 4 of 15

be conducting deliveries and management of complica-

tions of pregnancy, labor, postpartum, and newborn, plus

all the aforementioned maternal and child health ser-

vices of health centre level II. If they are employed and

placed to work in an health centre IV and hospital, which

by design has an additional obstetric theatre, anesthesia

facilities, and a medical doctor, they will be assisting or

actually conducting anesthesia or the cesarian section in

addition to the aforementioned maternal and child health

services for health centre level II and III. This is expected

because medical doctors are in short supply and the few

available are busy attending to healthcare needs of other

patients, such as those with emergency medicine, inter-

nal medicine, pediatrics, surgery, gynecology, orthope-

dics, ophthalmology, or ear, nose, and throat conditions

in addition to general administration and management of

the health facility [28]. Arguably, the decentralization plus

liberalization of the healthcare service delivery in Uganda

to include privately owned health facilities [29] will see

that the midwives with higher education will be employed

by private sector health facilities because they are less

expensive than physicians, and government facilities will

continue to hire the less expensive diploma midwives.

Intervention

As an evidence-based and relevant innovation to address

maternal and newborn health problems in Uganda, a four-

year Bachelor of Science in Midwifery (BScM) and a two-

year Master of Science in Midwifery (MScM) programme

(hereafter referred to as graduate midwifery education

programmes) were conceived. The scope of practice for

midwives that has been used to develop both of the pro-

posed advanced graduate midwifery educational programs

is based on the World Health Organization (WHO) and

International Confederation of Midwives (ICM) definitions

of the midwife. Advanced midwifery practice includes the

autonomous provision of healthcare to the girl-child, the

adolescent and the adult woman prior to, during, and fol-

lowing pregnancy and post-partum and care of the new-

born. This means that the advanced practice midwife gives

necessary healthcare, advice, and supervision to women

of reproductive health and their children before and dur-

ing pregnancy, labor, and the postpartum period. The

advanced practice midwife provides antenatal care and

conducts deliveries on his or her own accord and also

provides healthcare to the child, mainly the newborn and

infants. The healthcare may include primary healthcare

within the community (i.e. basic medical consultations,

diagnosis, treatment, health promotion, and preventive

interventions such as immunization, growth monitoring,

vitamins, and micro-nutrient supplementations); health

counseling, information, and education for women, the

family, and the community including preparation for

parenthood; provision of family planning methods; the

detection and treatment of abnormal medical conditions

in women of reproductive age, pregnant women, or post-

partum mothers and their children; the provision and or

referral for specialized care as necessary; medical consul-

tation, medical diagnostic tests, and analysis or surgery;

and the execution of primary and secondary interventions

for obstetrical emergencies in close collaboration with

obstetrician and gynecologists.

The objective of developing graduate midwifery educa-

tion programs was to incorporate critical surgical obstet-

rics and newborn care competences and skills required

to reduce the leading causes of maternal and newborn

deaths in Uganda and sub-Saharan Africa at large. As

noted earlier and in Table 2, Uganda’s midwifery prob-

lem is not total lack of midwives as there are over 40

health training institutions that churn out over 4,000

[30] of diploma and certificate level midwives per year.

Also to note that there are comprehensive training

programmes such Bachelor of Science in Nursing (BSc

Nursing), Registered Comprehensive Nursing (RCN), and

Enrolled Comprehensive Nursing (ECN) that train stu-

dents in both nursing and midwifery skills and therefore

are also regarded as avenues of producing midwives in

Uganda.

Table 2: Midwifery education system in Uganda.

Training programme Duration Award Entry schemes

MSc Midwifery 2 years Master’s Bachelor

BSc Midwifery 4 years Bachelor’s UACE/Diploma or Mature age

BSc Nursing 4 years Bachelor’s UACE/Diploma or Mature age

BSc Nursing completion 2.5 years Bachelor’s Nursing or midwifery diploma

BSc Midwifery completion 2.5 years Bachelor’s Midwifery or nursing diploma

RCN 4 years Diploma UACE or nursing certificate

Registered Midwifery 3 years Diploma UACE or midwifery certificate

RME 1.5 years Diploma Certificate in Midwifery

ECN 2.5 years Certificate UCE

Enrolled Midwifery 1.5 years Certificate UCE

MSc is Master of Science; BSc is Bachelor of Science; UACE is Uganda Advanced Certificate of Education; RCN is Registered Compre-

hensive Nursing; RME is Registered Midwifery Extension; ECN is Enrolled Comprehensive Nursing; UCE is Uganda Certificate of

Education.

Kumakech et al: Graduate Midwifery Education in Uganda Art. 52, page 5 of 15

The shortage is in midwives with advanced education

(Bachelor’s and Master’s level) and thus advanced compe-

tence to manage complications of pregnancy, labor, post-

partum, and the newborn in addition to managing the

normal pregnancy, labor, postpartum, and newborn care

in which the enrolled certificate and registered diploma-

level midwives obtain training and practice. The dura-

tion of training of certificate and diploma-level midwives

ranges from 2.5 years for enrolled certificate in midwifery,

three years for registered diploma in midwifery and even

four years if registered diploma in comprehensive nurs-

ing is also included. Comparing the above durations for

training enrolled certificate and registered diploma-level

midwives and the four years duration for training of the

degree level BSc Midwives, the four years is not that long

enough to affect interest and enrollment of candidates. In

the results section of this paper, we present the attractive-

ness of the BSc Midwifery programme in terms of trends

in student enrolment and graduation rates.

Methodology

It was in 2013 that Lira University, a public university in

remote Northern Uganda, in partnership with Seed Global

Health, implemented the first Bachelor’s degree mid-

wifery education program in Uganda with further possi-

bilities of advancing it to Master’s level by the year 2020.

The University has its own Lira University Teaching Hospi-

tal (Figure 2).

In addition to the basic midwifery skills such as ante-

natal care, management of minor maternal and newborn

disorders, monitoring of progress of labor, management

of normal delivery and newborn care, graduate midwives

also have competencies in conducting breach delivery,

management of shoulder dystortia, forceps delivery,

evacuation and emergency obstetrics and newborn care

(EMONC).

Also incorporated are advanced newborn care com-

petences such as neonatal resuscitation, kangaroo

mother/father care, cord care with chlorhexidine 7.1%,

antibiotic therapy, incubation, phototherapy, Vscan, et cet-

era. Additional competences include anesthesia and theatre

techniques, assisted cesarian section and first and second

line management of major maternal and newborn disor-

ders in antepartum, intrapartum, and postpartum periods.

Seed Educators from the USA supported capacity build-

ing for Lira University staffs, equipping of skills laboratory,

and teaching of students. The Seed Educators were mainly

nurse-midwives who came for a yearlong placement.

While at Lira University, they contributed to curriculum

review, classroom and clinical teaching of students, and

faculty and equipping of the clinical skills laboratory with

manikins among others.

It is important to note that the BSc Midwifery curricu-

lum has about 60% midwifery and 40% contents of other

fields. Other fields include the basic health sciences (i.e.

anatomy, physiology, biochemistry, microbiology, pathol-

ogy, and pharmacology), humanities and behavioral sci-

ences (i.e. sociology and anthropology), public health

sciences (i.e. epidemiology and biostatistics, communica-

ble disease control, nutrition, and research methods) and

clinical nursing sciences (i.e. primary healthcare, medical,

surgical, pediatric, and psychiatric nursing care). These

are intentional designed to broaden the student’s foun-

dation and background for better understanding of the

midwifery specialty and also for future careers in other

fields. Therefore, transition from Bachelor’s to Master’s

level in midwifery provides the students with an addi-

tional two years for concentrating on midwifery courses

with minimal interference from other fields and becom-

ing truly advanced practice midwives. More importantly,

it is a period for the students to sharpen competences in

managing complications of pregnancy, labor, postpartum,

and the newborn, as expected of advance practice mid-

wives. Just like any other health field, the transition from

Bachelor’s to Master’s level midwives is likely to attract

fewer numbers of midwives who are interested in special-

izing and becoming future leaders, researchers, and edu-

cators of the midwifery profession.

For purposes of understanding the attractiveness of

the innovated training in midwifery, Lira University and

Ministry of Health records provided data on curriculum

content, students’ enrollment, and clinical midwifery

internship practice. These were mainly quantitative data

on student’s enrollment and completion/graduation

disaggregated by year. Similarly, for understanding the

relevance, aspects of maternal or newborn outcome and

impact of the training, an interactive conversation was

held with 22 (14 female, 8 male) of the practicing mid-

wives. Participants’ selection was purposive to ensure

balance in the year of completion/graduation from the

program, gender, healthcare facility level, public-private

ownership, and geographical region location.

The interviews with the selected graduate midwives

focused on the advanced midwifery skills they learnt from

the program, how successful they were at performing the

skills in clinical midwifery practice, and the correspond-

ing maternal or newborn outcomes, whether they are

applying them in their workplace, the skills they were not

able to practice, and what the challenges or barriers are.

The student midwives were contacted through telephone

or email. All the interviews with the graduate midwives

involved the first author, and they happened during the

period July 2019–March 2020. Transcripts of the inter-

views provided the source of the qualitative data.

Figure 2: Showing Lira University Teaching Hospital

where the Midwifery students conduct clinical practice

and patient care.

Kumakech et al: Graduate Midwifery Education in Uganda Art. 52, page 6 of 15

Quantitative data from the records such as Lira University

student midwives enrollment and graduation numbers

were analyzed for percentages and line graphs are used

to show trends in enrollment and completion/gradua-

tion. Qualitative data from the graduate midwives’ clini-

cal experience interview notes were analyzed to establish

whether the graduate midwives are practicing the added

skills or not and what the challenges and barriers are in

their respective workplaces. Also, simple frequency tallies

were used to establish the extent of exposure to a given

skill among the graduate midwives. Qualitative data from

interviews with the graduate midwives were analyzed

using manifest content analysis technique and reported in

narrative format with direct quotations.

Findings

Internship Placement

The findings from record review indicated that 356 stu-

dents (40.2% male, 59.8% female) enrolled in the BSc

Midwifery programme over the six years of the program

(2013–2018) and the enrollment is on an increasing trend

as shown in Figure 3.

The duration of midwifery practice of the graduate mid-

wives ranged from 6–30 months. The graduate midwives

with six months of practice experience were those from

the 2015 cohort, who started midwifery practice in 2019,

while those with 30 months of practice were from among

the 2013 cohort, who started practice in 2017. The prac-

tice setting spans all the categories and levels of hospitals,

a geographical mix, a rural-urban balance, and a public-

private balance (Table 3).

Performance of the advance midwifery skills

during internship practice

The findings from the interviews with the graduate mid-

wives shown in Table 4 revealed that all the graduate

midwives were able to perform 92% (59 out of the 64) of

the advanced obstetrics, gynecology, and abnormal new-

born care (neonatology) skills from their training. One of

them explained the practice as follows:

During my practice, I was able to carry out the

so called “difficult deliveries”, providing care as

required even in a resource-limited setting. I was

able to conduct so many breech deliveries, twin

deliveries, managed emergencies like shoulder dys-

tocia, the mighty postpartum hemorrhage that has

claimed lives of many mothers and almost attained

99.9% survival of my mothers and their babies

(Female graduate midwife from the 2014 cohort).

Figure 3: Trend in students’ enrollment into Bachelor

of Science in Midwifery programme at Lira University

Uganda (2013–2018).

70 76 74

2013 2014 2015 2016 2017 2018

Male

Female

Total

Table 3: Midwifery practice sites of the graduate midwives.

Practice site Facility category Number of midwives

Maracha hospital Northwestern rural public district general hospital 1

Nebbi hospital Northwestern rural public district general hospital 1

Lacor hospital Northern private general hospital 1

Kitgum hospital Northern rural private general hospital 1

Lira hospital Northern urban public regional referral hospital 1

Mbale hospital Eastern urban public regional referral hospital 2

Jinja hospital Eastern urban public regional referral hospital 2

Mulago hospital Central urban public national referral hospital 1

Mengo hospital Central urban private hospital 1

Case hospital Central urban private general hospital 1

Naguru hospital Central urban public general hospital 1

Mubende hospital Central rural public regional referral hospital 1

Bombo hospital Central rural military general hospital 1

Masaka hospital Southwestern rural public regional referral hospital 1

Kalisizo hospital Southwestern public district general hospital 1

Mbarara hospital Southwestern rural public regional referral hospital 1

Ishaka hospital Southwestern rural private general hospital 2

Fort portal hospital Western rural public regional referral hospital 2

Kumakech et al: Graduate Midwifery Education in Uganda Art. 52, page 7 of 15

As shown in Table 4, there were 16 top advanced obstet-

rics and newborn care skills performed by most of the

graduate midwives at their clinical workplaces. These

include postpartum hemorrhage (PPH) management,

pre-eclampsia management, breech delivery, neonatal

resuscitation, eclampsia management, twin delivery,

antepartum hemorrhage (APH) management, premature

rupture of membranes (PROM) management, shoulder

dystocia management, manual vacuum aspiration (MVA)

of retained products of conception, manual removal of

retained placenta (MRRP), assisting in cesarean section

(C/S), dilatation and curettage (D&C), urinary tract infec-

tions (UTI) in pregnancy management, and premature

baby care.

Many of the graduate midwives placed in rural dis-

trict general hospitals where there are no obstetricians

and gynecologists performed most of the added obstet-

rical skills solo. One of them explained his solo man-

agement of a case of premature rupture of membrane

as follows:

I received a prime gravida with complaint of drain-

ing liquor, I observed her and she was not pushing

or grunting. The abdomen had no previous cesar-

ian section scar, no horizontal ridges across lower

abdomen. I felt the abdomen for contractions fre-

quency; duration was mild, each lasting less than

20 seconds; fundal height was 38/40; fetal lie was

longitudinal; presentation was cephalic and fetal

movement not felt. I listened to the fetal heartbeat,

was 140 beats/minute. I checked for maternal

blood pressure (BP), temperature, pallor, sunken

eyes, all were normal. On vaginal examination,

there was no bulging perineum, no vaginal bleed-

ing, but there was visible leaking amniotic fluid,

which was not meconium stained. I performed dig-

ital vaginal examination and found cervical dilata-

tion was 2 cm and < 2 contraction in 10 minutes. I

administered prophylaxis antibiotics Ampicillin 2g

start. Did and obtained Bishop Score of 8. I chose to

perform induction of labor with hormonal method

using Oxytocin. I administered Oxytocin IV 2.5 IU

in 500 mL of normal saline at start infusion rate

of 10 drops/minute. I increased infusion rate by

10 drops every 30 minutes (max 60 minutes) until

good contraction pattern was established (3–5 con-

tractions in 10 minutes, each lasting >40 seconds).

I maintained this rate until delivery was complete.

The mother had normal spontaneous vaginal deliv-

ery to baby girl, 2.5 kg. Both mother and baby were

discharged in good conditions (Male graduate mid-

wife of 2014 cohort).

Table 4: The top 16 advance obstetric and newborn care skills perform by the graduate midwives during clinical

practice, their specific roles and the maternal and newborn outcomes.

Sn Advance obstetric and new-

born care skills performed

Tallies

total

Tallies by midwives’ specic

roles during the performance

Maternal

outcome

(+ vs. – )

Newborn

outcome

(+ vs. – )

Solo

actor

Team

member

Assisting

Physician

1 PPH management 12 1 10 1 12 vs. 0 NA

2 Pre-eclampsia management 11 11 0 0 11 vs. 0 11 vs 0

3 Breech delivery 10 7 3 0 10 vs. 0 10 vs. 0

4 Neonatal resuscitation 9 8 1 0 NA 7 vs. 2

5 Eclampsia management 8 3 5 0 8 vs. 0 6 vs. 2

6 Twin delivery 8 6 2 0 8 vs. 0 8 vs. 0

7 APH management 7 7 0 0 7 vs. 0 7 vs. 0

8 PROM management 5 3 2 0 5 vs. 0 5 vs. 0

9 Shoulder dystocia management 5 2 3 0 4 vs. 1

5 vs. 0

10 MVA 5 5 0 0 5 vs. 0 NA

11 MRRP 4 4 0 0 4 vs. 0 NA

12 Assisting in C/S delivery 4 0 0 4 4 vs. 0 4 vs. 0

13 D&C 4 4 0 0 4 vs. 0 NA

14 Malaria in pregnancy manage-

ment

3 3 0 0 3 vs. 0 3 vs. 0

15 UTI in pregnancy management 3 3 0 0 3 vs. 0 3 vs. 0

16 Premature baby care 3 0 3 0 NA 2 vs. 1

One baby was a fresh still birth and the other died from the from neonatal intensive care unit (NICU).

One mother got second-degree tear, which was repaired.

One baby died on the resuscitation table and the second one died in the NICU.

Kumakech et al: Graduate Midwifery Education in Uganda Art. 52, page 8 of 15

Additionally, there are other added skills performed by

at least two of the midwives in their respective clinical

practices with positive outcomes for both the moth-

ers and babies. These include assisting in laparotomies

for ectopic pregnancies, cord prolapse delivery, cutting

and repairing of episiotomies, repairing of second-

degree tears, abortion management, cervical cancer

screening, prolonged labor management, uterine rup-

ture management where one mother died, post-abor-

tion care, obstructed labor management, induction of

labor, vacuum extraction, preoperative care, postop-

erative care, prolonged labor management and neona-

tal sepsis management. One of the graduate midwives

explained how he successfully managed postpartum

hemorrhage and how the success brought him joy as

a midwife:

PPH (postpartum hemorrhage) claims many lives

of mothers in Uganda, and at times it poses a night-

mare for midwives and doctors. During my three-

month rotation in labor suite, I faced eight differ-

ent PPH cases. Terrifying at the first encounter but

with more composure, I resolved and determined

my mindset and well prepared with equipment

and necessary materials, I managed PPH cases

after personally conducting the deliveries or after

the student midwives (certificate and diploma

midwife) with help of mainly senior midwives and

intern doctors. This was through various interven-

tions, which included uterine massage, Oxytocin

infusion, expelling clots, emptying the bladder by

urinary catheter, repairing mainly second-degree

tears, and using balloon tamponade. It brought

much joy and satisfaction to me when homeostasis

was achieved and the mother was in stable condi-

tion with healthy baby (Male graduate midwife of

2014 cohort).

More so, there are other added skills performed by at

least one graduate midwife during their clinical practices

with positive outcomes for both the mothers and babies.

These include severe hyperemesis gravidarum manage-

ment, assisting in laparotomies for ectopic pregnancies,

family planning method particularly intrauterine contra-

ceptive device and implants counseling and insertion,

birth asphyxia management, fetal distress management,

intrauterine fetal death management, sickle cell crisis in

pregnancy management, intrauterine fetal resuscitation,

infertility management, cervical dystocia management,

post-term pregnancy management, birth defect coun-

seling and referral, compound presentation management,

arm prolapse management, placenta pacrater manage-

ment, triplet delivery, sexually transmitted infection (STI)

treatment, molar pregnancy management, unconscious

mother in labor management, ectopic pregnancy man-

agement, neonatal jaundice management, anemia in

pregnancy management, puerperal sepsis management,

neonatal necrotizing enterocolitis management, neonatal

hypothermia management, and neonatal respiratory dis-

tress management.

Another most exciting bit was when I was manag-

ing third stage of labor after I delivered the baby.

I followed all the steps of AMTSL (active manage-

ment of third stage of labor), but to my surprise,

the placenta could not be delivered for some good

time despite of all the intervention. Mother was

not bleeding and the placenta showed me that it

was not about to be delivered. I thought of option

B that was manual removal. I shared the option

with my senior; she said its fine go on. I prepared

to deliver the placenta manually, guess what, when

held the cord with my left hand and as I followed

the cord with the other hand trying to locate the

edges of the placenta, I realized the cord was enter-

ing to the uterine wall. I was shocked. We called the

gynecologist; he told me it was placenta pacrater.

She was later taken in for hysterectomy (Female

graduate midwife from 2014 cohort).

There were only five added skills that the graduate mid-

wives were not able to perform during their clinical prac-

tice. These were performing cesarean section, laparoto-

mies for ectopic pregnancy, symphysiotomy, and repair

of third- and fourth-degree perineal tears. The challenges

and barriers are listed in Table 5, which ranges from

few or total lack of patients with the indications for the

intervention. Also, some graduate midwives were denied

the chance to perform the procedures by their supervi-

sors due to the misperception that they are not qualified

enough or the procedure or intervention should be per-

formed by physicians who have the authentic license or

permit to perform the procedures.

It is important to note that even for skills like manual

vacuum aspiration, dilatation and curettage, vacuum

extraction, forceps deliveries and assisting in cesarian sec-

tion (C/S) deliveries, which were performed by a few of the

graduate midwives from rural hospitals, it is not universal

as such. Some clinical supervisors in some of the above

hospitals blocked the graduate midwives from perform-

ing the procedures on the ground being that they are not

qualified enough, or the government of Uganda has not

yet licensed them to perform those skills. Other graduate

midwives simply did not perform the added skills because

of lack of cases with the indications for the intervention or

just lack of equipment or facilities. Several graduate mid-

wives commented on this:

I was not permitted to perform cesarean section,

exploratory laparotomy for ectopic pregnancy, nor

vacuum delivery. Most reasons pointed towards

lack of clear guidelines and policies in relation

to midwives’ license to perform such procedures

(Male graduate midwife from 2013 cohort).

Some conditions like shoulder dystocia are very

rare. I haven’t come across one in six months. Here,

procedures like manual vacuum aspiration, dilata-

tion, and curettage are purely for doctors (Female

graduate midwife from 2014 cohort).

I did not do cases concerning shoulder dystocia,

deliveries by vacuum extraction, manual removal

Kumakech et al: Graduate Midwifery Education in Uganda Art. 52, page 9 of 15

of the retained placenta because there was high

competition for skills among the intern midwives,

intern doctors, and students (Female graduate mid-

wife from 2014 cohort).

Post-internship Work and Application of the Added

Skills

Of the 34 students in the first 2013 cohort, 94.1% gradu-

ated and completed internships in record time. Post-clin-

ical midwifery internship employment status of the 32

midwives who completed internships show that by Janu-

ary 2019, 25% were retained at Lira University Hospital as

Midwives and Teaching Assistants, 62.5% gained employ-

ment in various maternal and newborn healthcare pro-

grams across Uganda. The remaining 12.4% ventured into

private midwifery practice. Overall, there is 88% retention

of the graduates at in-country hospitals.

As noted above, quite a good number of the gradu-

ate midwives from the 2013 cohort were retained at

Lira University and Lira University Teaching Hospital. In

the teaching hospital, they are involved in teaching stu-

dents, supervising and mentoring diploma midwives, and

research in addition to participating in managing mothers

with obstetrics and gynecological conditions. The work of

the graduate midwives in teaching hospitals is explained

as follows:

I am currently working at Lira University and Lira

University Teaching Hospital as a Teaching Assis-

tant in the Department of Nursing and Midwifery.

I teach, set examination, and supervise students

in the clinical areas, attend ward rounds, give

treatment to patients, monitor mothers in labor,

conduct deliveries, supervise other clinical staffs

[diploma midwives] in my unit and participate in

research. I am able to apply most of the obstet-

rics skills l learnt like managing a mother with

pre-eclampsia and eclampsia, PPH (post-partum

hemorrhage), shoulder dystocia, resuscitating new-

borns, manual removal of retained placenta, etc.

(Female graduate midwife from 2013 cohort).

Notably, the graduate midwives from the 2014 cohort

have also finished internship practice and entered into

the job market. Of the nine of them in this study sam-

ple, seven are employed and working. Two of them were

employed in Sanyu Africa Research Institute – one as a

research midwife, where she is applying research skills

– and one in the International Rescue Committee as a

reproductive health officer, responsible for programming

reproductive health services in a refugee settlement.

Some of them were employed as nursing officers in mid-

wifery at Mbarara Regional Referral Hospital, which has

all the necessary equipment or instruments for managing

obstetric complications and therefore are able to apply

the added obstetrics skills. One of them described the fol-

lowing:

I am currently working with Global Health Col-

laboration that partners with Mbarara Regional

Referral Hospital as a nursing officer–midwifery,

and l do clinical work in the obstetrics and gyne-

cology department. I am able to apply the follow-

ing abnormal midwifery skill: management of PPH,

breach delivery, episiotomy and repair of both epi-

siotomy and perineal tears up to second degree,

newborn resuscitation, twin deliveries, and cord

prolapse deliveries (Male graduate midwife from

2014 cohort).

Some graduate midwives from the 2014 cohort are

employed and working in remote lower-level public

health centres (Warr health centre IV in Zombo district

in northern Uganda and Namisindwa health centre III in

Namisindwa district in Eastern Uganda). The one working

in health centre IV with a theatre facility is able to assist

in cesarian section delivery, conduct pre- and post-oper-

ative care and neonatal resuscitation. The one working

Table 5: Challenges and barriers for the graduate midwives’ failure to perform some of the added skills.

Sn Added skills not or underperformed The challenges or barriers responsible

1 Delivering babies with shoulder dystocia from both rural

and urban regional referral hospitals

Cases are rare, high competition amongst health workers for

the few available cases; some clinical supervisors prefer to

refer the cases to theatre for operation by physicians instead of

first giving the chance for the graduate midwives to manage.

2 Performing symphysiotomy from urban and rural regional

referral hospitals and even rural district general hospital

Clinical supervisors block the graduate midwives from

performing symphysiotomy, on the premise that they are not

experienced enough to safely perform the procedure

3 Performing of C/S delivery from urban and rural

regional referral hospitals and even rural district general

hospitals

Clinical supervisors block the graduate midwives from

performing C/S delivery, on the premise that they are not

licensed for the role

4 Performing laparotomies for ectopic pregnancies from

urban and rural regional referral hospitals and even rural

district general hospitals

Clinical supervisors block the graduate midwives from

performing C/S delivery, on the premise that they are not

licensed for the role

5 Repairing of third- and fourth-degree perineal tears from

national and regional referral hospitals

Clinical Supervisors block the graduate midwives from repair-

ing of third and fourth degree perineal tears, on the premise

that they are not licensed for the role

Kumakech et al: Graduate Midwifery Education in Uganda Art. 52, page 10 of 15

in health centre III with a maternity ward but no theatre

and equipment for managing obstetric cases is only able

to conduct the routine antenatal care, delivery of mothers

with normal labor, referral of high-risk mothers to higher-

level health facilities and managing the maternity ward.

The work of the graduate midwives in the lower level pri-

mary care health facilities with maternity ward but with-

out theatre or equipment for managing obstetric cases is

described as follows:

I work with Namisindwa local government, which

is one of the newly created districts in Uganda, as

nursing officer – midwifery in health center three.

It is a very hard-to-reach area with a health center

three being the highest level of care facility in the

entire district.

The work I do are: organizing and participating

in departmental meeting; ordering, balancing,

and keeping drugs and supplies records updated;

making of duty rosters and ensuring all duties are

covered accordingly; writing weekly and monthly

reports; coaching and mentoring the junior staff

on new midwifery knowledge and skills to ena-

ble efficient and quality service or care delivery

to all mothers and their unborn babies; work-

ing hand-in-hand with visiting medical person-

nel to improve on services given to clients; [and]

performing activities like ensuring cleanliness of

the department, managing deliveries, providing

general nursing care to all clients entrusted in

my care, preventing and treating minor ailments,

early identification of complications and referring

for appropriate care to Mbale regional referral hos-

pital because the district has no capacity to handle

any emergency cases (Female graduate midwife

from 2013 cohort).

The practice is a bit different for those employed in urban

private general hospitals. There are many high-risk moth-

ers but their obstetricians and gynecologists are always

available for them and do much caring to prevent the

occurrence of the obstetric complications. Consequently,

the graduate midwives conduct normal deliveries, normal

newborn care and postnatal care where there are limited

chances of applying their added obstetrics skills. One of

them had this to explain:

Currently, I am working at Case Hospital as a mid-

wife for experience as I am looking for a better

job. I am majorly working in labor ward and NICU

(Neonatal Intensive Care Unit). Being a private set-

ting [hospital], it is a different protocol all together.

Mostly, we work hand-in-hand with the gynecolo-

gists and pediatricians. They are there for each of

their mothers and newborns. In most cases, they

do a lot of preventive measures as a result there

are few cases of abnormal midwifery. The few are

pre-eclampsia, twin delivery, PROM (premature

rupture of membranes), etc. But personally the

only challenge I faced was during PPH (post-par-

tum hemorrhage) caused by cervical tear (Female

graduate midwife from 2014 cohort).

Discussion

Our study showed increasing trends in both enrolment

and graduation from the four-year-long training for grad-

uate midwives in Uganda. This is an evidence that the

training is both attractive and attainable. The four years of

the training is worth the extra obstetric surgical skills that

the students acquire if compared to the four years train-

ing for diploma in comprehensive nursing, the three years

training for diploma in midwifery and 2.5 years training

for certificate in midwifery where the candidates come

out with skills for providing normal midwifery and new-

born care.

The above finding from Uganda concurs with finding of

career retention survey conducted among Bachelor’s and

Associate’s degree nurses in the US state of Vermont that

found that Bachelor’s nurses were employed for longer

periods of time, despite Bachelor’s education requiring

more time to complete (4 years) compared to Associate’s

Degree nurses (2–3 years) [31]. In the time of health

workforce shortage, the longer duration of careers for

Bachelor’s nurses compared to Associate’s Degree nurses

is an important social return.

Our study further revealed that the graduate midwives

are retained to work in primary maternal and newborn

care facilities across Uganda. This is not a mere point on

the relevance of the training but also gives a renewed

hope of mothers and newborns benefiting from their

added obstetric surgical competences and also providing

leadership to certificate and diploma midwives in primary

care facilities. The employment of the graduate mid-

wives in primary care facilities like hospitals and health

centres ensures quality healthcare are nearer to where

pregnant mothers and their newborns live. More so, our

study revealed that graduate midwives are employable

in academic facilities where they provide teaching and

mentorship to students, certificate and diploma level mid-

wives in both clinical and classroom areas. Also exciting

to note is our finding that graduate midwives are employ-

able in research roles, where they participate in advancing

the midwifery profession with new knowledge.

The aforementioned employment opportunities for

graduate midwifery educational programmes are not sur-

prises because the training equips students with clinical,

research, management, leadership, and teaching skills to

practice in the primary care settings (i.e. health centres),

in hospitals, schools of nursing and midwifery, universi-

ties, research organizations and other settings including

community-based healthcare programming. With the

increasing awareness amongst the job market stakehold-

ers about the added obstetrical surgical skills of the gradu-

ate midwives, the employment prospects for the graduate

midwives are becoming broader than the ones identified

from this study, to span governmental [32] and non-gov-

ernmental organizations and the private sectors as well in

neighboring countries like Kenya [33], as listed in Table 6.

The above finding concurs with the findings from the sur-

vey conducted among Bachelor’s and Associate’s Degree

Kumakech et al: Graduate Midwifery Education in Uganda Art. 52, page 11 of 15

nurses in the US state of Vermont, which indicated that

Bachelor’s nurses enter careers earlier and are employed

for longer durations compared to the Associate’s degree

nurses [31]. In the time of a health workforce shortage,

the time to career is an important social return, indicat-

ing that there were more job opportunities for Bachelor’s

nurses, enabling them to get jobs more quickly compared

to their Associate’s degree counterparts.

Importantly, our study revealed that the graduate mid-

wives are helping to bridge obstetric surgical skill gaps in

primary care facilities in Uganda where there are neither

medical officers nor obstetricians and gynecologist phy-

sicians or are available but busy with provision of other

medical services or administrative duties. This to us is the

most critical contribution where the graduate midwives

will register future impact on maternal and newborn

health outcomes.

Our data revealed that while performing all the roles

and responsibilities, the graduate midwife uses evidence-

based guidelines, protocols, and approaches from mid-

wifery, nursing, medical, and other health sciences. The

graduate midwives are trained to be able to take leader-

ship and assume responsibility for providing appropriate

healthcare services including the prescribing, adminis-

tering and dispensing of pharmacologic agents includ-

ing drugs and therapeutics especially in the antenatal,

labor, and postnatal care areas. Notably, in the Uganda

health system, even the certificate and diploma midwives

are already licensed by health authorities to prescribe,

administer, and dispense drugs for treatment of minor

disorders in pregnancy, labor, and postpartum, including

iron sulphate, folic acid, and anthelminthic drugs, includ-

ing those for prevention of malaria in pregnancy. They

are, however, restricted from treating high-risk mothers,

such as those with underlying medical conditions (diabe-

tes, sickle cell disease, heart disease, etc.), whom they are

expected to refer to physicians, particularly obstetricians

and gynecologists. The certificate and diploma midwives

are also restricted from managing mothers and newborns

with severe complications of pregnancy, labor, and post-

partum such as those with hemorrhage, pre-eclampisa,

etc. The restriction is based on the fact that their short

2.5–3 years training does not include skills for managing

high-risk mothers and those with severe complications

of pregnancy, labor and postpartum. Despite the afore-

mentioned restrictions of certificate and diploma mid-

wives based on their limited competence, Uganda hasn’t

yet managed to train enough physicians to deploy in all

levels of primary care facilities. Health centres level II–III,

and even many level IV primary care facilities in Uganda,

do not have physicians to manage the aforementioned

maternal and newborn high-risk conditions and complica-

tions. Therefore, the expanded skills and scope of practice

of the graduate midwives will add values to every level of

Ugandan health system, as explained in Table 7.

With increasing awareness of the value additions from

the graduate midwives’ added obstetric skills, we listed in

Table 7 all the practice settings within Uganda health sys-

tem where the graduate midwives would qualify to seek

employment should there be job openings in midwifery,

maternal, and child health fields.

The finding of our study concurs with several previous

studies that pointed to a strong link to improvement in

patient outcomes from four-year bachelor’s level educa-

tion of nurses in the Europe. Aiken et al. (2014) in a study

in nine European countries found that every 10% increase

in a bachelor’s degree nurse was associated with a 7%

decrease in likelihood of inpatient dying [34].

Our data found out that the major post-training practice

challenge experienced by the graduate midwives is lack of

recognition of their extra obstetric surgery skills by other

health cadres and thus denying them official opportuni-

ties to use the added obstetric surgical skills to save lives.

Another challenge was the deployment of the graduate

midwives in lower-level primary care facilities, such as

health centre III which does not have the necessary capac-

ity (in terms of infrastructure, equipment, protocols, sup-

plies and drugs) to allow the graduate midwives apply the

obstetric surgical skills.

The above findings concur with a study conducted in

Malawi, which indicated a tension between Bachelor’s

degree nurses and diploma nurses in a clinical setting,

whereby the diploma nurses often do not feel confident or

want to support the degree nurses [35]. Tension between

cadres is normal during introduction of new cadre of

health professionals. It should be prevented through a

Table 6: Employment Prospects for Graduate Midwives in Uganda.

Primary healthcare providers in midwifery and maternal child health specialties

Midwifery clinical specialists

Clinical researcher, research coordinators, quality control and monitoring officers

Midwife educators or lecturers

Principal nursing officers – midwifery in governmental, non-governmental, and private healthcare sectors

Reproductive health, maternal child health program/project officers or managers

Clinical leaders in reproductive health and family planning service organizations

Private midwifery practice in homes or maternity homes

Primary healthcare providers in midwifery and maternal child health specialties

Entrepreneurs providing midwifery/maternity services, primary, and reproductive health services

Kumakech et al: Graduate Midwifery Education in Uganda Art. 52, page 12 of 15

Table 7: Examples of value addition from graduate midwives to the Uganda health system.

Ugandan health system Value additions from the graduate midwives well and above those being provided

by the existing certicate and diploma midwives

Health centre level I, which is a

mobile voluntary village health team

without physical infrastructure.

No value addition

Health centre level II primary care

facility, which has an outpatient

department without maternity ward

or physician

Increased management of moderate to severe complications of pregnancy, postpartum,

and the newborn. This is because the certificate and diploma midwives can only manage

the minor disorders. Additionally, there will be reduction in referrals to higher-level facili-

ties of mothers and newborns for management of moderate-severe complications and

thus saving time and cost to families. Lastly, there will be an improved leadership and

management in the maternal child health department.

Health centre level III primary

care facility which has an outpa-

tient department, maternity ward,

laboratory testing but no theatre or

physician

Increased management of moderate to severe complications of pregnancy, labor, post-

partum, and the newborn. This is because the certificate and diploma midwives can only

manage the minor disorders. More so, there will also be reduction in presumptive diag-

nosis of maternal and newborn conditions from increased ordering of laboratory testing

from the graduate midwives, which will improve the accuracy of diagnosis, treatments,

and reduce drug wastage. Additionally, there will be reduction in referrals to higher-level

facilities of mothers and newborns for management of moderate to severe complications

including complications of labor and thus saving time and cost to families. Lastly, there

will be an improved leadership and management in the maternal child health depart-

ment, labor, and postnatal wards.

Health centre level IV primary care

facility which has an outpatient

department, maternity ward, labora-

tory testing, theatre and physician.

The physician often one position is

also administrative and management

duties of the health centre. In addi-

tion, to note that most of the level

IV facilities have no physicians nor

anesthetic officers for the operation

of the theatre.

Increased management of moderate to severe complications of pregnancy, labor, post-

partum and the newborn. This is because the certificate and diploma midwives can only

manage the minor disorders. More so, there will also be reduction in presumptive diag-

nosis of maternal and newborn conditions from increased ordering of laboratory testing

from the graduate midwives, which will improve the accuracy of diagnosis, treatments

and reduce drug wastage. Additionally, there will be reduction in referrals to hospitals of

mothers and newborns for management of moderate to severe complications includ-

ing complications of labor and thus saving time and cost to families. Also, there will

be an improved leadership and management in the maternal child health department,

labor, and postnatal wards. There will be increased cesarean section rate and improved

outcomes of mothers from theatre as the graduate midwives will improve preoperative

care, increase assistance of the physician during cesarean section, improve anesthesia

and theatre techniques, improve postoperative care, and improve newborn care from

resuscitation. If the facility does not have a physician, the graduate midwives will perform

emergency cesarean section if licensed to do so.

Hospitals Increased management of moderate to severe complications of pregnancy, labor,

postpartum, and the newborn. This is because the certificate and diploma midwives can

only manage the minor disorders. More so, there will also be reduction in presumptive

diagnosis of maternal and newborn conditions from increased ordering of laboratory

testing from the graduate midwives, which will improve the accuracy of diagnosis and

treatments and reduce drug waste. Additionally, there will be a reduction in referrals to

hospitals of mothers and newborns for management of moderate to severe complica-

tions, including complications of labor and thus saving time and cost to families. Also,

there will be an improved leadership and management in the maternal child health

department, labor, and postnatal wards. There will be increased cesarean section rate

and improved outcomes of mothers from theatre as the graduate midwives will improve

preoperative care, increase assistance of the physician during cesarean section, improve

anesthesia and theatre techniques, improve postoperative care, and improve newborn

care from resuscitation. If the facility does not have a physician, the graduate midwives

will perform emergency cesarean section if licensed to do so.

District health office as assistant

district health officer – nursing and

maternal child health

Improvement in the management, particularly midwifery, maternal, and child health

services in the district from quality technical monitoring, supervision, mentorship of

certificate and diploma midwives at health facilities.

Health development partners work-

ing on maternal child health pro-

grams as program officers, technical

advisors, project managers, etc.

Improvements in quality of programs for midwifery, maternal, and child health in the

district health office and health facilities.

Kumakech et al: Graduate Midwifery Education in Uganda Art. 52, page 13 of 15

scheme of service with updates to cater for scope of prac-

tice of the new cadre. Uganda has changed its scheme of

service to include Bachelor’s and Master’s nurses and mid-

wives [36] and this change will prevent tension between

various cadres of nurses and midwives.

Conclusion

Graduate midwifery education at Lira University in

Uganda is an innovation that is attracting high student

enrolment. The retention of the graduates into clinical

practice settings in Uganda further provides opportuni-

ties for addressing maternal and newborn health prob-

lems, quality issues in midwifery practice, gaps in clinical

research, and gaps in leadership of the midwifery profes-

sion in Uganda.

Recommendations

Larger tracer studies of the graduate midwives to identify

the kinds of obstetric surgeries and newborn care services

they ably performed and their corresponding maternal

and newborn health outcomes is recommended. Also rec-

ommended is advocacy for recognition of extra skills of

graduate midwives by the health authorities in Uganda.

Funding Information

Funding for this article was provided by Seed Global

Health.

Competing Interests

The authors have no competing interests to declare.

Author Contributions

• EdwardKumakechparticipatedinconceivingthe

idea of the manuscript, wrote the initial draft of the

manuscript, compiled comments from co-authors,

and made revisions.

• JulieAnathanparticipatedinconceivingtheideaof

the manuscript, reviewed the draft manuscript, and

provided comments.

• SamsonUdhoreviewedthedraftmanuscriptand

provided comments. Anna Grace Auma reviewed

the draft manuscript and provided comments. Irene

Atuhaire reviewed the draft manuscript and provided

comments. Allan G. Nsubuga reviewed the draft

manuscript and provided comments. Bonaventure

Ahaisibwe reviewed the draft manuscript and pro-

vided comments.

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Kumakech et al: Graduate Midwifery Education in Uganda Art. 52, page 15 of 15

How to cite this article: Kumakech E, Anathan J, Udho S, Auma AG, Atuhaire I, Nsubuga AG and Ahaisibwe B. Graduate

Midwifery Education in Uganda Aiming to Improve Maternal and Newborn Health Outcomes.

Annals of Global Health

. 2020;

86(1):52, 1–15. DOI: https://doi.org/10.5334/aogh.2804

Published: 21 May 2020

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